Why are Dutch GPs so much happier?

General practice is similar in the Netherlands and the UK yet it appeals far more to young Dutch doctors than to their British counterparts. In collaboration with the Dutch medical journal Nederlands Tijdschrift voor Geneeskunde, Roger Damoiseaux, professor of general practice, and Margaret McCartney, Glasgow GP and The BMJ columnist, met to try to work out why.

Sophie Arie reports Sophie Arie freelance journalist, London

In many ways, the daily work of a general practitioner in the Netherlands and the United Kingdomis similar.Working hours, pay, and time spent with patients are comparable (table⇓). Increasing numbers of GPs work part time in both countries, and they struggle with the same pressures of caring for an ageing population amid constant cuts to welfare, social services, and healthcare.

Yet the job is respected and popular in the Netherlands, with 1250 young medical graduates competing for 750 trainee posts last year, whereas 451 GP trainee posts were unfilled in the UK in 2014. In a wide ranging discussion with Roger Damoiseaux, professor of general practice at Utrecht University, Glasgow GPMargaretMcCartney says the public image of the profession in the UK and the policies of the current government are part of the reason. Damoiseaux points to several key strengths of the profession in the Netherlands that may explain why it is stronger both politically and in terms of status than in the UK.

Strong union
“In the Netherlands GPs have a very strong position in healthcare,” says Damoiseaux. The National Association of General Practitioners (LVH) represents 80% of all GPs. “They take care of the salaries, negotiations with the minister, and also how we organise general practice. So it’s a very strong group of professionals and I think that is seen by the public and also by the students,” he says.

The strength of the GPs’ union to negotiate with government, Damoiseaux believes, partly explains why Dutch students are attracted to the profession. In the UK, GPs have no union of their own. Some 31 985 of the 40 584 GPs (79%) are members of the British Medical Association, the trade union for all UK doctors.

Respected guidelines
Another key difference Damoiseaux points out is that the Dutch College of General Practitioners has since 1989 drawn up its own guidelines on how to treat specific conditions in primary care. It started with diabetes and now has guidelines on around 100 conditions.

“We make them ourselves. They are supported by all GPs. And it’s easy to say to specialists “this is what we do,” says Damoiseaux.

By contrast, guidelines in the UK are set down by the National Institute for Health and Care Excellence and cover both primary and hospital care.

“Our guidelines in general are given to us from on high. They are not really written for GPs in the front line dealing with people with undifferentiated symptoms, most of whom will not have the diagnosis that the guidelines have been written about,” says McCartney.

“I think this is key to the way primary care sees itself and the way others see it: not valid enough to do our own research and our own work with our own stipulations of what’s good and what isn’t. We have terrible trouble persuading some people sometimes that not following some guidelines is actually very much in the best interest of the patient.”

Support from government
Damoiseaux says that wherever it can the Dutch government supports GPs because it sees primary care as its ally in the effort to save costs in secondary care. Whereas, McCartney says, in the UK the current government’s approach to the NHS as a whole has united GPs and specialists in opposition to the government and to specific government policies amid a sense of misdirection.

Damoiseaux explains that in some ways the Dutch insurance based system gives Dutch GPs greater power to negotiate between insurance companies and the government for what they want.

“Insurance companies are private companies,” he says. “There are several—five or six—in the Netherlands so there is a certain room to negotiate about things. Sometimes the union even goes back to the minister and says, ‘We just don’t want to do it like this or we will not do the other things we’ve planned together.’” Damoiseaux describes a grass roots revolt this year by Dutch GPs, who refused to cooperate when insurance companies attempted to impose more box ticking and targets. By contrast, McCartney says, British GPs are frustrated that the Quality and Outcomes Framework has reduced consultations to a box ticking process.

“I think a lot of GP energy has been expended doing the wrong stuff for too long,” she says, referring to GPs becoming involved in commissioning hospital services under changes introduced in 2004. That shift was stressful for a lot of GPs and took them away from their patients. “I think that changed a lot of doctors’ perceptions of what it is that GPs do or don’t do.”

Image of the profession
McCartney also feels strongly that in the UK, the media’s portrayal of general practice, combined with attitudes towards the profession in some medical schools, discourages some students before they have any direct experience of the job. “I think a lot of doctors coming through (medical school) will have a look at what people think about general practitioners and won’t like what they hear,” says McCartney. “There are some universities that are popular breeding grounds for GPs and other universities that hardly seem to produce any. Some senior doctors think that’s because health professionals [in those universities] speak down about GPs sometimes.”

The Royal College of General Practitioners is currently running a campaign, “There’s nothing general about general practice,” to try to change negative attitudes. But, says McCartney, there

has long been too much public focus on the problems GPs face rather than the joys of the job. Damoiseaux says that, in contrast, the image of the profession is strong in the Netherlands. Although many medical students want to be surgeons or enter other specialties, all medical schools in the Netherlands seem to give students positive insights into general practice and the media do not overemphasise what’s wrong with the profession.

Salaries
McCartney also says uncertainty for GPs over their salaries is demoralising working GPs and putting off young doctors. Whereas Dutch GPs’ salaries have remained stable for years, in the UK they have been falling for the past few years. GPs were given a large rise because they were earning far less than specialists, McCartney says, but that was then seen as being too much and since then it has been declining. “To a certain extent that gives instability because you don’t quite know what’s going to happen next,” says McCartney. “I would rather just know how much money I had than worry that it is going up and down all the time.”

Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Listen to the full discussion in The BMJ podcast Provenance and peer review: Commissioned; not externally peer reviewed.